Azimuth Counseling and Therapeutic Services, Inc. Couple s Information Form

Transcription

1 1) Name: 2) Age: 3) Date: / / 4) Address: City: State: Zip: 5) Briefly, what is your main purpose in coming to couple s counseling? Instructions: To assist us in helping you, please fill out this form as fully and openly as possible. Your answers will help plan a course of couple s therapy that is most suitable for you and your partner. Do not exchange this information with your partner at this time. Several of your answers on this form may be shared later with your partner during joint therapy sessions if you give us permission to share this information. For this reason you are advised to respond honestly and carefully to each item. If certain questions do not apply to you or you do not want to share this information, please leave them blank. 6) Have you been married before? Yes No If Yes, how many previous marriages have you had? ) How long have you and your partner been in this relationship? 8) Are you and your partner presently living together? Yes No 9) Are you and your partner engaged to be married? No Yes When? 10) Fill out the following information for each child of whom the natural parent is both you and your partner, children from previous relationships, and adopted children. Neither of us has children (go to next page) One or each of us has children(continue) Whose Child s name Age Sex Child? * Lives with you both? 1) F M Yes No 2) F M Yes No 3) F M Yes No 4) F M Yes No 5) F M Yes No 6) F M Yes No 7) F M Yes No 8) F M Yes No * Whose child? answering options: B = Both of ours, natural child BA = Both of ours, adopted (or taken on) M = My natural child MA = My child, adopted (or taken on) P = Partner s natural child PA = Partner s child, adopted (or taken on) 1

2 11) List five qualities that initially attracted you to your partner: Does your partner still possess this trait? 12) List four negative concerns that you initially had in the Does your partner still relationship: possess this trait? 13) List five present positive attributes of your partner: Do you often praise your partner for this trait? 14) List five present negative attributes of your partner: Do you nag your partner about this trait? 15) List five things you do (or could do) to make the marriage Do you often implement more fulfilling for your partner: this behavior? 16) List five things that your partner does (or could do) to make Does your partner often the marriage more fulfilling for you: implement this behavior? 2

3 17) List five expectations or dreams you had about Has this been relationships before you met your partner: fulfilled? 18) On a scale of 1 to 5 rate the following items as they pertain to: 1) The present state of the relationship 2) Your need or desire for it 3) Your partner s need or desire for it Circle the Appropriate Response for Each (If not applicable, leave blank.) Present state of Your need Partner s need the relationship or desire or desire Poor Great Low High Low High 1) Affection ) Childrearing rules ) Commitment together ) Communication ) Emotional closeness ) Financial security ) Honesty ) Housework sharing ) Love ) Physical attraction ) Religious commitment ) Respect ) Sexual fulfillment ) Social life together ) Time together ) Trust Other (specify) 17) ) ) ) )For couples living together. Which partner spends more time conducting the following activities? Circle the Appropriate Response for Each (If not applicable, leave blank.) (M = Me P = Partner E = Equal time) Is this equitable (fair)? Comments 1) Auto repairs M P E Yes No 3

4 2) Child care M P E Yes No 3) Child discipline M P E Yes No 4) Cleaning bathrooms M P E Yes No 5) Cooking M P E Yes No 6) Employment M P E Yes No 7) Grocery shopping M P E Yes No 8) House cleaning M P E Yes No 9) Inside repairs M P E Yes No 10) Laundry M P E Yes No 11) Making bed M P E Yes No 12) Outside repairs M P E Yes No 13) Recreational events M P E Yes No 14) Social activities M P E Yes No 15) Sweeping kitchen M P E Yes No 16) Taking out garbage M P E Yes No 17) Washing dishes M P E Yes No 18) Yard work M P E Yes No 19) Other: M P E Yes No 20) Other: M S E Yes No 20) If some of the following behaviors take place only during MILD arguments circle an M in the appropriate blanks. If they take place only during SEVERE arguments, circle an S. If they take place during ALL arguments circle an A. Fill this out for you and your impression of your partner. If certain behaviors do not take place, leave them blank. Circle the Appropriate Response for Each (M = Mild arguments only S = Severe arguments only A = All arguments) Behavior By me By partner Should this change? 1) Apologize M S A M S A Yes No 2) Become silent M S A M S A Yes No 3) Bring up the past M S A M S A Yes No 4) Criticize M S A M S A Yes No 5) Cruel accusations M S A M S A Yes No 6) Cry M S A M S A Yes No 7) Destroy property M S A M S A Yes No 8) Leave the house M S A M S A Yes No 9) Make peace M S A M S A Yes No 10) Moodiness M S A M S A Yes No 11) Not listen M S A M S A Yes No 12) Physical abuse M S A M S A Yes No 13) Physical threats M S A M S A Yes No 14) Sarcasm M S A M S A Yes No 15) Scream M S A M S A Yes No 16) Slam doors M S A M S A Yes No 17) Speak irrationally M S A M S A Yes No 18) Speak rationally M S A M S A Yes No 19) Sulk M S A M S A Yes No 4

5 20) Swear M S A M S A Yes No 21) Threaten breaking up M S A M S A Yes No 22) Threaten to take kids M S A M S A Yes No 23) Throw things M S A M S A Yes No 24) Verbal abuse M S A M S A Yes No 25) Yell M S A M S A Yes No 26) M S A M S A Yes No 27) M S A M S A Yes No 28) M S A M S A Yes No 21) How often do you have: Mild arguments? Severe arguments? 22) When a MILD argument is over 23) When a SEVERE argument is over how do you usually feel? how do you usually feel? Check Appropriate Responses Check Appropriate Responses Angry Lonely Angry Lonely Anxious Nauseous Anxious Nauseous Childish Numb Childish Numb Defeated Regretful Defeated Regretful Depressed Relieved Depressed Relieved Guilty Stupid Guilty Stupid Happy Victimized Happy Victimized Hopeless Worthless Hopeless Worthless Irritable Irritable 24) Which of the following issues or behaviors of you and/or your partner may be attributable to your relationship or personal conflicts? If an item does not apply, leave it blank. Circle the Appropriate Responses (M = My behavior P = Partner s behavior B = Both) Alcohol consumption M P B Perfectionist M P B Childishness M P B Possessive M P B Controlling M P B Spends too much M P B Defensiveness M P B Steals M P B Degrading M P B Stubbornness M P B Demanding M P B Uncaring M P B Drugs M P B Unstable M P B Flirts with others M P B Violent M P B Gambling M P B Withdrawn M P B Irresponsibility M P B Works too much M P B Lies M P B Other (specify) Past marriage(s)/relationship(s) M P B M P B Other s advice M P B M P B Outside interests M P B M P B Past failures M P B M P B 5

6 25) In the space below please provide additional information that would be helpful: I,, hereby give my permission for this clinic to share the information that I provide on this form to (partner) when it is deemed appropriate by an agreement between me, my partner, and our therapist. This sharing of information may take place only during a joint counseling session (both partners present). Client s signature: Date: / / PLEASE RETURN THIS AND OTHER ASSESSMENT MATERIALS TO THIS OFFICE AT LEAST TWO DAYS BEFORE YOUR NEXT APPOINTMENT. 6